Healthcare Provider Details

I. General information

NPI: 1083802136
Provider Name (Legal Business Name): RENEE THORNTON-ROOP LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955A MOUNTAIN LAUREL CIR SE
ALBUQUERQUE NM
87116-1252
US

IV. Provider business mailing address

955A MOUNTAIN LAUREL CIR SE
ALBUQUERQUE NM
87116-1252
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-6284
  • Fax:
Mailing address:
  • Phone: 505-266-6284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-06575
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: